Date : 00.00.00
Name of the Patient : Abc Xyzati Dlmn / F / 48 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE.
H/O lumbar spine surgery for PID at the L4-L5 level on 00.00.00.
M.R.I of the lumbo-sacral spine was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and T2 Weighted axial images.
There is evidence of laminectomy at the L4, L5 and S1 vertebral levels with post-operative changes in the posterior soft tissues at these levels.
There are left paracentral and left bilateral postero-lateral disc herniations at the L4-L5 level with neural foraminal narrowing and indentation on the traversing left L5 nerve root and both exiting L4 nerve roots. Slight superior migration of the disc fragment is noted. The L4-L5 intervertebral disc is reduced in height and shows loss of water content. The L4 and L5 vertebral bodies adjacent to the L4-L5 disc appear hypointense on all the pulse sequences. The rest of the L4 and L5 vertebral bodies appear slightly hyperintense to normal marrow on the T2 Weighted images. Hypertrophic facetal arthropathy is noted at the L4-L5 level, bilaterally, more so on the right side.
There is a posteriorly bulging disc with a peridiscal osteophyte at the L5-S1 level, with bilateral neural foraminal narrowing. Hypertrophic facetal arthropathy and ligamentum flavum hypertrophy is also noted. Small effusion is noted in the right facet joint at the L5-S1 level. Probable inflammation of the exiting left L5 nerve root is noted.
The intrathecal nerve roots at the L3, L4 and L5 vertebral levels appear slightly thickened and which may suggest arachnoiditis.
The L2-L3, L3-L4 and L5-S1 intervertebral discs show loss of water content.
The rest of the lumbar vertebral bodies reveal normal signal intensity. The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12-L1 level and the thecal sac terminates at the S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
15.0 mm at L1-L2
16.0 mm at L2-L3
14.0 mm at L3-L4
10.0 mm at L5-S1.
1. Post-operative status.
2. Left paracentral and bilateral postero-lateral disc herniations at the L4-L5 level with indentation on the traversing left L5 nerve root and both the exiting L4 nerve roots.
- 3 - Scan-00005
3. Altered signal in the L4 and L5 vertebral bodies adjacent to the L4-L5 disc may be the sequelae of previous surgery.
4. Hypertrophic facetal arthropathy at the L4-L5 level, bilaterally, more on the right side.
5. A posteriorly bulging disc with a peridiscal osteophyte at the L5-S1 level, with hypertrophic facetal arthropathy and ligamentum flavum hypertrophy at that level and a small effusion in the right facet joint at the L5-S1 level.
6. Thickened intrathecal nerve roots at the L3, L4 and L5 vertebral levels may suggest arachnoiditis.